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6 STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING - 03 EPDXY LINING ( ) 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING 03 CATHODIC PROTECTION ( 1 04 UNKNOWN �✓05 NONE <br /> ( ) 06 TAR OR ASPHALT ( ) 09 OTHER: /` <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> 4CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN (�7 NONE <br /> B. UNDERGROUND PIPING: ( l 01 DOUBLE-WALLED PIPE ( 1 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> _(CHECK APPROPRIATE BOX(ES) fk) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> ( ) 01 VISUAL PXJ 02 STOCK INVENTORY 04 VAPOR SNIFF WELLS K) 05 SENSOR INSTRUMENT 'TAaJi�— YL—E(�EVLEAGT TLS <br /> -it <br /> ( 1 06 GROUND WATER MONITORING WELLS (j� 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: P)PIKJG' KBE QMS £Op <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASU (IF KNOWN) CHEMICAL (DO NOT USE <br /> STORED STORED COMMERCIAL NAME) <br /> ( ) O1 ( ) 02 ( 1031 1 1 1 1 1 1 11 1 1 1 1 <br /> ( ) <br /> 01 (_) 02 ( ) 03 I I I I I—LIWI I I 11 I I I II <br /> ( ) 01 ( ) 02 ( ) 03 L1�_ <br /> ( 101 ( ' 02 ( 203LLLLII_LIIIII <br /> 01 02 03 1 1 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> O01 O02 O03IIlIIIIII1111 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> 1 ) <br /> 01 ( ) 02 ( 1 03 <br /> O <br /> 01 I ) 02 O 03 I I I I I I I I I I I <br /> FIS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( ) 01 YES (>4 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGEr IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATURE) PHONE W/AREA CODE <br /> FOR LOCAL AGENCY USE ONLY <br /> nOMI ISTRATING AGENCY CITY CODE <br /> COUNTY CODE <br /> CONT <br /> T PERSON / PMONEWW�/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATELOCAL PERMIT ID # <br /> ( ) 01 YES ( ) 02 NO <br /> HSC04-070185 <br /> PAGE 2 <br />